Wednesday, March 27, 2013

Transabdominal Cerclage

I'm not usually one to publicly talk about my reproductive organs. If words like uterus, cervix, transvaginal ultrasound, and dilation make you twitch, you may just want to skip this post ;) My hope is that this information helps other women navigate their choices for family planning after their preemie or loss.

On Friday I will be taking the first step in doing everything possible to a full term or nearly full term healthy baby.

No, I am not pregnant.

No, We aren't planning a second baby in the immediate future.

Yes, we would like to eventually have another child.

Tomorrow I am traveling to New Jersey and on Friday I will be getting an Transabdominal Cerclage (TAC) by one of the best and most experienced doctors in the TAC world. The transabdominal cerclage is a procedure where they open the abdomen in a similar fashion to a c-section and place a strong fabric band around the top of the cervix, just under the uterus. It essentially keeps the cervix from effacing and dilating and is especially effective because it is placed at the very top of the cervix, eliminating any dilating force or funneling. The decision to have this surgery has not been an easy one. There have been many consultations with many doctors with many different opinions to get to this point.

Almost all of the doctors agreed that I had a congenitally weak cervix. In addition to having a previously diagnosed uterine septum and surgery to remove it, I also showed all of the classic signs of cervical incompetence: I was fully effaced at 22 weeks and had painless dilation thereafter. There was no sign of infection, my membranes did not rupture, and Virginia was completely perfect- all things that could have made the diagnosis of cervical incompetence a little more hazy. I did not have a single uncomfortable contraction until I was over 7 cm dilated. Even then I could have convinced myself that the aches were something other than impending birth.

Some doctors suggested a "wait and see" approach to a future pregnancy. Umm ... no thanks, we were all shocked at how quickly my cervix changed then stabilized and then changed again. I am not willing to risk that approach.

Some doctors suggested a Transvaginal Cerclage (TVC) at 12 weeks into a future pregnancy. I very seriously considered this option. The problem in my case is that I had severe funneling (opening at the top of the cervix) weeks before I had any cervical dilation (opening at the bottom of the cervix). I honestly think a TVC could be successful for me, but not without a whole lot of angst, bedrest and hospitalization. I have no doubt that if I were to get a TVC that I would be funneled to the stitch by 20-22 weeks. Cue... lots of panic. I simply cant do that to myself, my husband, my family, and most importantly Virginia.

I don't think anyone would have even mentioned a TAC none the less suggested the procedure if I had not asked about it. There are only a handful of doctors in the US that do these procedures regularly. Unfortunately this leads to a lack of statistics and awareness among the obstetrics and patient community.

I was completely shocked when I read the statistics - A TAC has a success rate of over 95%** for bringing pregnancies to term (37 weeks gestation). A preventative (as opposed to a rescue) TVC has less than a 75%** success rate. Most obstetricians and Maternal Fetal Medicine (MFM) specialists view the TAC as an extreme measure saved for people that have had 3 or more 2nd trimester losses. The all too common complacency to intervene earlier in the wake of of 2nd trimester loss or extreme prematurity when the cause is clearly cervical incompetence is completely baffling and appalling to me. No one should have to lose 3 or more babies to be at least be presented with all of the options for intervention.

The TAC is certainly more invasive than the other options. It is an open abdominal surgery (open in my case but it can also be done laproscopically). The TAC eliminates the possibility for delivering a baby vaginally. For me, a vaginal delivery is not an option because I had a classic c-section with a vertical incision to my uterus. There is a higher risk of uterine rupture with a classic incision, so laboring and vaginal deliveries are definitely not recommended. This made my decision for a TAC much easier.

The decision was not made lightly but we feel this is the best one for our family. We believe it gives me the best chance for carrying to term. We believe it gives me the best chance to avoid bedrest and more importantly hospital bedrest. Do we think a future pregnancy will be "normal"? no way. Will we be scared sh*tless still? Absolutely.

If you have some good thoughts to spare, I'll take them. I'm hoping that this the dawn of a new day for us and someday helps bring us a big, chubby and healthy baby.

In the meantime things might be a little quiet around here. Heath is holding down the fort with Virginia at home and Moma will be with me in NJ for a few days. I'm hoping to be home in time to spend Easter with Virginia.

** These statistics were quoted to me by my physician. I will add some of the published research that I came across some time in the future.

12 comments:

It sounds like you have made a well thought out and informed decision! I'll be sending good thoughts your way...I'm actually headed to New Jersey this afternoon for the long weekend:) So glad you are helping educate others on options for IC. I've been reading so much about TAC's lately...word is getting out!! Stay well:)Rachel

I am also wondering about what recovery was like...was the TAC placed under general anesthesia? Was it an outpatient procedure? Did you have restrictions following the TAC placement? I am 28 weeks pregnant and have a TVC. It took the doctor over an hour to place the TVC (average time is typically 10-15 min) and he had a very difficult time finding any cervical tissue to stitch together. He actually stitched my lower uterine body. He said going back he would never have done a TVC. I almost wish I had gotten a TAC then but I had never heard of it, they didn't list it as an option. I was 1.8 cm before TVC (due to LEEP and cone following cervical cancer) then went up to 5cm after the TVC, my last measurement 3 weeks ago was 2.2cm. I have another measurement tomorrow. Anyway, the MFM and obgyn say the only hope we have of another child is a TAC before conception. Could you please let me know your thoughts on TAC since having the procedure. Thanks!

First of all, I hope you have a long and healthy pregnancy. Good luck with your measurement tomorrow... Im hoping that it is steady since your last measurement.

My TAC was done by Dr. George Davis in NJ. It was an open procedure with an incision very similar to a c-section and was done under general anesthesia. My understanding is that he only uses spinal anesthesia for his patients getting a TAC during pregnancy. I stayed one night in the hospital which is standard for his patients. Dr. Davis suggested that I take it easy for a few weeks after surgery. He advised that I not drive until I was comfortable jumping off of one step and that I dont do anything that is painful (really specific, huh?!). I had help with my 20lb daughter for the first week and just avoided alot of picking up/carrying her for the first 2 weeks. I didnt go back to exercising for 5 weeks post surgery. Honestly, the recovery was much easier than I expected.

The TAC does require that you have a c-section delivery. My daughter was born via classical c-section so I am not eligible for a VBAC anyway so this was not a strong consideration for me. The TAC essentially takes the cervix out of the equation though so it really is a perfect treatment for women that have short or weak cervixes.

I would suggest getting in contact with Dr Davis or Dr Haney after you are settled with your baby and when you are ready to think about future pregnancies. They both do phone consults and are incredibly knowledgable. You may also want to look up the abbyloopers yahoo or facebook sites.

Did you get the TAC? I'm struggling so bad right now with what to do. I just don't want to chance it. I lost my triplets in May... it's eating me alive that I didn't know about this. I would have moved heaven and earth to save them. I could not. Now as we look into the future I'm so confused. Everyone is pushing a TAC for good reason, but I'm scared of a c-section... I had horrible blood loss. But I guess it comes down to I am more scared to lose another child. I can't survive it a second time. jesusmeandphotography.blogspot.com